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Hypertension: Overview

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Hypertension: Overview

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Hypertension Definitions

Overview:

Hypertension is characterized by sustained elevated blood pressure.

Hypertension is common worldwide, and, according to updated guidelines, approximately 46% of Americans 20 years and older have hypertension.
Many of these individuals are unaware of their status, which is why hypertension is sometimes referred to as a "silent killer."

Hypertension predisposes patients to cardiovascular disease, which is one of the most common causes of death in both men and women worldwide.

Review of blood pressure and its determinants:
Review Cardiac Cycle

Systolic pressure is the highest arterial pressure, reached after blood is ejected from the left ventricle.
– 120 mmHg

Diastolic blood pressure is the lowest arterial pressure, reached during ventricular relaxation.

  • 80 mmHg

Mean arterial pressure is determined by Cardiac Output and Total Peripheral Resistance.

  • 93 mmHg

Cardiac output refers to the amount of blood ejected by the left ventricle in in one minute

Total Peripheral Resistance refers to the resistance of the systemic arteries to blood flow (total peripheral resistance is also referred to as systemic vascular resistance, SVR).

Hypertension occurs when the cardiac output and/or total peripheral resistance increases.

Classification of Hypertension:
2017 guidelines by the American College of Cardiologists and American Heart Association.

Healthy/normotensive: Systolic blood pressure less than 120 mmHg, and diastolic pressure less than 80 mmHg.

Elevated: Systolic blood pressures between 120 and 129 mmHg, and diastolic pressures less than 80 mmHg.

Stage 1 hypertension: Systolic pressures between 130 and 139 mmHg, OR diastolic pressures between 80 and 89 mmHg.

Stage 2 hypertension: Systolic pressures above 140 mmHg, OR diastolic pressures above 90 mmHg.

The higher value determines the stage of hypertension if the systolic and diastolic values fall in different categories.

  • For example, if a patient's systolic pressure is 135 mmHg and but diastolic pressure is 75 mmHg, it would be classified as Stage 1 hypertension.

Blood pressure fluctuates throughout the day and in response to various situations, so multiple measurements need to be taken in and out of the health clinic, and during waking and sleeping.

One frustrating aspect of measuring blood pressure is that the presence of a health care professional can affect the blood pressure! This may be due to sympathetic activation in response to anxiety or other factors.
"White coat hypertension" occurs when an untreated patient has high blood pressure in the presence of a medical professional, but is otherwise normotensive.

"White coat effect" is the same phenomenon, but in patients who are under treatment for high blood pressure.

"Masked hypertension" is when an untreated patient is normotensive in the presence of a medical professional but is hypertensive otherwise;

"Masked uncontrolled hypertension" is the same phenomenon, except in patients who are being treated for hypertension.

Primary Hypertension

Primary hypertension accounts for 90-95% of all adult cases of hypertension.

In primary hypertension, there is no single identifiable cause.

Instead, one or more of the following factors contribute to high blood pressure:
Genetic and epigenetic factors can contribute to development of high blood pressure.

Obesity contributes to hypertension via various direct and indirect mechanisms; for example, some propose that dysfunction in the sympathetic nervous system and kidneys contribute to high blood pressure in obese patients.

Sedentary lifestyles which are common in societies where we spend several hours per day at our desks.

  • Increasing physical activity confers multiple protective effects on the cardiovascular system.

Diet is a significant predictor of hypertension

  • Particularly salt intake and salt sensitivity. Salt sensitivity refers to how efficiently individuals excrete salt and, therefore, avoid elevations in blood pressure. Exactly what determines salt sensitivity is uncertain, but African-Americans, the elderly, and post-menopausal women seem to be particularly susceptible to elevations in blood pressure due to lower rates of salt excretion.
  • Inadequate intake of other nutrients, including calcium, potassium, vegetable proteins, and fiber may also contribute to hypertension.

Alcohol as well as electronic and tobacco cigarettes are associated with hypertension due to their effects on the sympathetic nervous system and other regulators of blood pressure.

Chronic stress, including psychosocial stress, also contributes to hypertension; this may be due to activation of the sympathetic nervous system and/or other physiological reactions to stress.

Population differences
Hypertension prevalence varies by population, and are likely due to differences in both genetic and environmental factors.
There are dramatic differences in the prevalence of hypertension in United States subpopulations, due to both genetic and environmental differences.

  • Hypertension prevalence is highest in non-Hispanic African Americans, American Indians, and Native Alaskans as compared to non-Hispanic Caucasian Americans and Hispanic Americans.

Age and sex
In general, hypertension prevalence increases with age.
Premenopausal women typically have lower blood pressures than do age-matched men or post-menopausal women.
Post-menopausal women* have blood pressures equal to or higher than their age-matched male peers.
To illustrate this, we draw a simple graph that shows that, as men and women age, blood pressure increases; after menopause, women's blood pressure levels exceed that of men's.

Note that some of these variables are modifiable, and many are interrelated.

Secondary Hypertension

Secondary hypertension accounts for 5-10% of adult hypertension.

In secondary hypertension, an underlying condition causes the elevation in blood pressure.

Causes include:

Renovascular hypertension occurs when renal artery stenosis prevents blood from reaching the kidneys; in response to low oxygen levels, the kidneys release hormones that increase blood pressure.

  • Notice that the adaptive physiological response to low oxygen levels is, in this case, contributing to pathology.
  • Two key causes of renal artery stenosis and renovascular hypertension are atherosclerosis and fibromuscular dysplasia.

Obstructive sleep apnea

Primary aldosteronism](/term/physiology/aldosterone-physiology-hyperaldosteronism) is characterized by adrenal glands that release excess aldosterone, which leads to increased sodium and fluid retention, and, therefore, increased blood volume and pressure.

  • Two key causes of primary aldosteronism and hypertension are aldosterone-producing adenomas and bilateral idiopathic hyperaldosteronism.

Renal parenchymal diseases also lead to hypertension due to inadequate blood volume regulation by damaged renal tissue.

Drugs

  • Examples: caffeine, NSAIDS, hormonal contraceptives (especially those with synthetic estrogen), decongestants, cocaine, amphetamines, and some herbal agents.

Pregnancy:pregnant women can develop gestational hypertension, which can lead to pre-eclampsia (aka, toxemia).

  • Hypertension is a significant cause of morbidity and mortality in both mothers and their neonates, and women who are hypertensive prior to pregnancy require special attention.

Additional Causes of Secondary Hypertension

Board Review

Hypertension

Getting ready for boards? Review these concise, bulleted high yield reviews for your exam.

USMLE & COMLEX-USA

Nurse Practitioner (NP)

Physician Assistant (PA)

Internal Medicine (ABIM)

Hypertension References

  • "2017 Guideline for High Blood Pressure in Adults." American College of Cardiology. Accessed March 12, 2019. http%3a%2f%2fwww.acc.org%2flatest-in-cardiology%2ften-points-to-remember%2f2017%2f11%2f09%2f11%2f41%2f2017-guideline-for-high-blood-pressure-in-adults.
  • Akbari, Pegah, and Arshia Khorasani-Zadeh. "Thiazide Diuretics." In StatPearls. Treasure Island (FL): StatPearls Publishing, 2019. http://www.ncbi.nlm.nih.gov/books/NBK532918/.
  • Bloomfield, Dennis A, and Alex Park. "Decoding White Coat Hypertension." World Journal of Clinical Cases 5, no. 3 (March 16, 2017): 82–92. https://doi.org/10.12998/wjcc.v5.i3.82.
  • Bramham, Kate, Bethany Parnell, Catherine Nelson-Piercy, Paul T. Seed, Lucilla Poston, and Lucy C. Chappell. "Chronic Hypertension and Pregnancy Outcomes: Systematic Review and Meta-Analysis." BMJ 348 (April 15, 2014): g2301. https://doi.org/10.1136/bmj.g2301.
  • Briant, L. J. B., N. Charkoudian, and E. C. Hart. "Sympathetic Regulation of Blood Pressure in Normotension and Hypertension: When Sex Matters: Sex Differences in Sympathetic Regulation of Blood Pressure." Experimental Physiology 101, no. 2 (February 1, 2016): 219–29. https://doi.org/10.1113/EP085368.
  • Burkholder, Greer A., Ashutosh R. Tamhane, Monika M. Safford, Paul M. Muntner, Amanda L. Willig, James H. Willig, James L. Raper, Michael S. Saag, and Michael J. Mugavero. "Racial Disparities in the Prevalence and Control of Hypertension among a Cohort of HIV-Infected Patients in the Southeastern United States." PLoS ONE 13, no. 3 (March 29, 2018). https://doi.org/10.1371/journal.pone.0194940.
  • Calhoun, David A. "Aldosteronism and Hypertension." Clinical Journal of the American Society of Nephrology 1, no. 5 (September 1, 2006): 1039–45. https://doi.org/10.2215/CJN.01060306.
  • Calhoun, David A., Ernesto L. Schiffrin, and John M. Flack. "Resistant Hypertension: An Update." American Journal of Hypertension 32, no. 1 (January 1, 2019): 1–3. https://doi.org/10.1093/ajh/hpy156.
  • "Cardioselective Beta Blocker Use in Patients With Asthma." Medscape. Accessed March 25, 2019. http://www.medscape.com/viewarticle/464040.
  • Carretero Oscar A., and Oparil Suzanne. "Essential Hypertension." Circulation 101, no. 3 (January 25, 2000): 329–35. https://doi.org/10.1161/01.CIR.101.3.329.
  • Carthy, Elliott R. "Autonomic Dysfunction in Essential Hypertension: A Systematic Review." Annals of Medicine and Surgery 3, no. 1 (March 1, 2014): 2–7. https://doi.org/10.1016/j.amsu.2013.11.002.
  • Choi, Hoon Young, Hyeong Cheon Park, and Sung Kyu Ha. "Salt Sensitivity and Hypertension: A Paradigm Shift from Kidney Malfunction to Vascular Endothelial Dysfunction." Electrolytes & Blood Pressure?: E & BP 13, no. 1 (June 2015): 7–16. https://doi.org/10.5049/EBP.2015.13.1.7.
  • "Clinical Significance of Endothelial Dysfunction in Essential Hypertension - ProQuest." Accessed March 13, 2019. https://search.proquest.com/openview/c2ce48078c1759aaa0aaac88e5f8aab1/1.pdf?pq-origsite=gscholar&cbl=326347.
  • Colafella, Katrina M. Mirabito, and Kate M. Denton. "Sex-Specific Differences in Hypertension and Associated Cardiovascular Disease." Nature Reviews Nephrology, January 30, 2018. https://doi.org/10.1038/nrneph.2017.189.
  • DeMarco, Vincent G., Annayya R. Aroor, and James R. Sowers. "The Pathophysiology of Hypertension in Patients with Obesity." Nature Reviews. Endocrinology 10, no. 6 (June 2014): 364–76. https://doi.org/10.1038/nrendo.2014.44.
  • Eibl, A. D., H. G. Predel, T. Sanders, and J. Zacher. "[Neuronal Blood Pressure Regulation]." Klinische Monatsblatter fur Augenheilkunde 236, no. 2 (February 2019): 145–49. https://doi.org/10.1055/a-0808-4843.
  • Esler Murray. "Sympathetic Nervous System Moves Toward Center Stage in Cardiovascular Medicine." Hypertension 63, no. 3 (March 1, 2014): e25–32. https://doi.org/10.1161/HYPERTENSIONAHA.113.02439.
    "Explore High Blood Pressure in the United States | 2018 Annual Report." America's Health Rankings. Accessed March 19, 2019. https://www.americashealthrankings.org/explore/annual/measure/Hypertension/state/ALL.
  • Feihl, François, Lucas Liaudet, Bernard Waeber, and Bernard I. Levy. "Hypertension: A Disease of the Microcirculation?" Hypertension 48, no. 6 (December 2006): 1012–17. https://doi.org/10.1161/01.HYP.0000249510.20326.72.
  • Felder, Robin A., Marquitta J. White, Scott M. Williams, and Pedro A. Jose. "Diagnostic Tools for Hypertension and Salt Sensitivity Testing." Current Opinion in Nephrology and Hypertension 22, no. 1 (January 2013): 65–76. https://doi.org/10.1097/MNH.0b013e32835b3693.
  • Frishman, William H. "Beta-Adrenergic Receptor Blockers in Hypertension: Alive and Well." Progress in Cardiovascular Diseases 59, no. 3 (November 2016): 247–52. https://doi.org/10.1016/j.pcad.2016.10.005.
  • Gkaliagkousi, Eugenia, Eleni Gavriilaki, Areti Triantafyllou, and Stella Douma. "Clinical Significance of Endothelial Dysfunction in Essential Hypertension." Current Hypertension Reports; Philadelphia 17, no. 11 (November 2015): 1–9. http://dx.doi.org.proxy.ulib.uits.iu.edu/10.1007/s11906-015-0596-3.
  • González, Jaime, Nicolás Valls, Roberto Brito, and Ramón Rodrigo. "Essential Hypertension and Oxidative Stress: New Insights." World Journal of Cardiology 6, no. 6 (June 26, 2014): 353–66. https://doi.org/10.4330/wjc.v6.i6.353.
  • Harvey, Adam, Augusto C. Montezano, and Rhian M. Touyz. "Vascular Biology of Ageing—Implications in Hypertension." Journal of Molecular and Cellular Cardiology 83 (June 2015): 112–21. https://doi.org/10.1016/j.yjmcc.2015.04.011.
  • Helmer, Allison. "A Review of ACE Inhibitors and ARBs in Black Patients With Hypertension," n.d., 9.
  • Herman, Linda L., and Khalid Bashir. "Angiotensin Converting Enzyme Inhibitors (ACEI)." In StatPearls. Treasure Island (FL): StatPearls Publishing, 2019. http://www.ncbi.nlm.nih.gov/books/NBK431051/.
  • Intengan, H. D., and E. L. Schiffrin. "Vascular Remodeling in Hypertension: Roles of Apoptosis, Inflammation, and Fibrosis." Hypertension (Dallas, Tex.: 1979) 38, no. 3 Pt 2 (September 2001): 581–87.
  • Intengan, Hope D, and Ernesto L Schiffrin. "Vascular Remodeling in Hypertension," n.d., 7.
    Julius Stevo, Pascual Arturo V., Sannerstedt Rune, and Mitchell Charles. "Relationship Between Cardiac Output and Peripheral Resistance in Borderline Hypertension." Circulation 43, no. 3 (March 1, 1971): 382–90. https://doi.org/10.1161/01.CIR.43.3.382.
  • Kang, Kyu-Tae. "Endothelium-Derived Relaxing Factors of Small Resistance Arteries in Hypertension." Toxicological Research 30, no. 3 (September 2014): 141–48. https://doi.org/10.5487/TR.2014.30.3.141.
  • Kobzik, Alexander, and Michael R. Pinsky. "Arterial Blood Pressure Regulation." In Hemodynamic Monitoring, edited by Michael R. Pinsky, Jean-Louis Teboul, and Jean-Louis Vincent, 39–48. Lessons from the ICU. Cham: Springer International Publishing, 2019. https://doi.org/10.1007/978-3-319-69269-2_5.
  • Lechi, Alessandro. "The Obesity Paradox: Is It Really a Paradox? Hypertension." Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity 22, no. 1 (March 1, 2017): 43–48. https://doi.org/10.1007/s40519-016-0330-4.
  • Lemarié, Catherine A., Pierre-Louis Tharaux, and Stéphanie Lehoux. "Extracellular Matrix Alterations in Hypertensive Vascular Remodeling." Journal of Molecular and Cellular Cardiology 48, no. 3 (March 2010): 433–39. https://doi.org/10.1016/j.yjmcc.2009.09.018.
  • Lloyd-Jones, Donald M., Pamela B. Morris, Christie M. Ballantyne, Kim K. Birtcher, David D. Daly, Sondra M. DePalma, Margo B. Minissian, Carl E. Orringer, and Sidney C. Smith. "2017 Focused Update of the 2016 ACC Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of
    Atherosclerotic Cardiovascular Disease Risk." Journal of the American College of Cardiology 70, no. 14 (October 2017): 1785–1822. https://doi.org/10.1016/j.jacc.2017.07.745.
  • Mayet, Jamil, and Alun Hughes. "Cardiac and Vascular Pathophysiology in Hypertension." Heart 89, no. 9 (September 2003): 1104–9.
  • McMaster William G., Kirabo Annet, Madhur Meena S., and Harrison David G. "Inflammation, Immunity, and Hypertensive End-Organ Damage." Circulation Research 116, no. 6 (March 13, 2015): 1022–33.
    https://doi.org/10.1161/CIRCRESAHA.116.303697.
  • Mosso Lorena, Carvajal Cristian, González Alexis, Barraza Adolfo, Avila Fernando, Montero Joaquín, Huete Alvaro, Gederlini Alessandra, and Fardella Carlos E. "Primary Aldosteronism and Hypertensive Disease." Hypertension 42, no. 2 (August 1, 2003): 161–65. https://doi.org/10.1161/01.HYP.0000079505.25750.11.
  • Mozaffarian, Dariush, Emelia J Benjamin, Alan S Go, Donna K Arnett, Michael J Blaha, Mary Cushman, Sandeep R Das, et al. "Heart Disease and Stroke Statistics—2016 Update," n.d., 323.
  • Mulvany, Michael J. "Small Artery Remodeling and Significance in the Development of Hypertension." Physiology 17, no. 3 (June 2002): 105–9. https://doi.org/10.1152/nips.01366.2001.
  • ———. "Structural Abnormalities of the Resistance Vasculature in Hypertension." Journal of Vascular Research 40, no. 6 (2003): 558–60. https://doi.org/10.1159/000075805.
  • Murthy, Meena, Thimo Kurz, and Kevin M. O'Shaughnessy. "WNK Signalling Pathways in Blood Pressure Regulation." Cellular and Molecular Life Sciences 74, no. 7 (April 1, 2017): 1261–80. https://doi.org/10.1007/s00018-016-2402-z.
  • Nakao Kazuhiro, Kuwahara Koichiro, Nishikimi Toshio, Nakagawa Yasuaki, Kinoshita Hideyuki, Minami Takeya, Kuwabara Yoshihiro, et al. "Endothelium-Derived C-Type Natriuretic Peptide Contributes to Blood Pressure Regulation by Maintaining Endothelial Integrity." Hypertension 69, no. 2 (February 1, 2017): 286–96. https://doi.org/10.1161/HYPERTENSIONAHA.116.08219.
    "NCHS Data on Racial and Ethnic Disparities," n.d., 2.
  • "New ACC/AHA High Blood Pressure Guidelines Lower Definition of Hypertension." American College of Cardiology. Accessed March 14, 2019. http%3a%2f%2fwww.acc.org%2flatest-in-cardiology%2farticles%2f2017%2f11%2f08%2f11%2f47%2fmon-5pm-bp-guideline-aha-2017.
    Oparil, Suzanne, Md M. Amin Zaman, and David A. Calhoun. "Pathogenesis of Hypertension." Annals of Internal Medicine, 2003, 761–776.
  • "Overview of Hypertension - Cardiovascular Disorders." Merck Manuals Professional Edition. Accessed March 12, 2019. https://www.merckmanuals.com/professional/cardiovascular-disorders/hypertension/overview-of-hypertension.
  • "Ovid: Vascular Remodeling in Hypertension: Roles of Apoptosis, Inflammation, and Fibrosis." Accessed March 14, 2019.
  • Piaditis, George, Athina Markou, Labrini Papanastasiou, Ioannis I. Androulakis, and Gregory Kaltsas. "PROGRESS IN ALDOSTERONISM: A Review of the Prevalence of Primary Aldosteronism in Pre-Hypertension and Hypertension." European Journal of Endocrinology 172, no. 5 (May 1, 2015): R191–203. https://doi.org/10.1530/EJE-14-0537.
  • Pilic, Leta, Charles R. Pedlar, and Yiannis Mavrommatis. "Salt-Sensitive Hypertension: Mechanisms and Effects of Dietary and Other Lifestyle Factors." Nutrition Reviews 74, no. 10 (October 1, 2016): 645–58. https://doi.org/10.1093/nutrit/nuw028.

vPioli, Mariana R, Alessandra MV Ritter, Ana Paula de Faria, and Rodrigo Modolo. "White Coat Syndrome and Its Variations: Differences and Clinical Impact." Integrated Blood Pressure Control 11 (November 8, 2018): 73–79. https://doi.org/10.2147/IBPC.S152761.

  • Puar, Troy Hai Kiat, Yingjuan Mok, Roy Debajyoti, Joan Khoo, Choon How How, and Alvin Kok Heong Ng. "Secondary Hypertension in Adults." Singapore Medical Journal 57, no. 5 (May 2016): 228–32. https://doi.org/10.11622/smedj.2016087.
  • Publishing, Harvard Health. "Medications for Treating Hypertension." Harvard Health. Accessed March 22, 2019. https://www.health.harvard.edu/heart-health/medications-for-treating-hypertension.
  • Ram, C. Venkata S. "Beta-Blockers in Hypertension." The American Journal of Cardiology 106, no. 12 (December 2010): 1819–25. https://doi.org/10.1016/j.amjcard.2010.08.023.
  • Rangaswami Janani, Bhalla Vivek, Blair John E.A., Chang Tara I., Costa Salvatore, Lentine Krista L., Lerma Edgar V., et al. "Cardiorenal Syndrome: Classification, Pathophysiology, Diagnosis, and Treatment Strategies: A Scientific Statement From the American Heart Association." Circulation 0, no. 0 (n.d.): CIR.0000000000000664. https://doi.org/10.1161/CIR.0000000000000664.
  • Renna, Nicolás F., Natalia de las Heras, and Roberto M. Miatello. "Pathophysiology of Vascular Remodeling in Hypertension." International Journal of Hypertension 2013 (2013): 1–7. https://doi.org/10.1155/2013/808353.
  • "Renovascular Hypertension - Cardiovascular Disorders - Merck Manuals Professional Edition." Accessed March 19, 2019. https://www.merckmanuals.com/professional/cardiovascular-disorders/hypertension/renovascular-hypertension.
  • Roush, George C., and Domenic A. Sica. "Diuretics for Hypertension: A Review and Update." American Journal of Hypertension 29, no. 10 (October 1, 2016): 1130–37. https://doi.org/10.1093/ajh/hpw030.
  • ———. "Diuretics for Hypertension: A Review and Update." American Journal of Hypertension 29, no. 10 (October 1, 2016): 1130–37. https://doi.org/10.1093/ajh/hpw030.
  • Shahin, Mohamed H, and Julie A Johnson. "Mechanisms and Pharmacogenetic Signals Underlying Thiazide Diuretics Blood Pressure Response." Current Opinion in Pharmacology 27 (April 2016): 31–37. https://doi.org/10.1016/j.coph.2016.01.005.
  • Siervo, Mario, Jose Lara, Shakir Chowdhury, Ammar Ashor, Clio Oggioni, and John C. Mathers. "Effects of the Dietary Approach to Stop Hypertension (DASH) Diet on Cardiovascular Risk Factors: A Systematic Review and Meta-Analysis." British Journal of Nutrition 113, no. 01 (January 2015): 1–15. https://doi.org/10.1017/S0007114514003341.
  • Soleimani, Manoocher. "Insulin Resistance and Hypertension: New Insights." Kidney International 87, no. 3 (March 1, 2015): 497–99. https://doi.org/10.1038/ki.2014.392.
  • Sonoyama, Kazuhiko, Adam Greenstein, Anna Price, Kaivan Khavandi, and Tony Heagerty. "Vascular Remodeling: Implications for Small Artery Function and Target Organ Damage." Therapeutic Advances in Cardiovascular Disease 1, no. 2 (December 2007): 129–37. https://doi.org/10.1177/1753944707086358.
  • Sug, Sung. "Hypertension Prevalence and Control Among Adults: United States, 2011–2014," no. 220 (2015): 8.
  • Sumners, Colin, Annette D. de Kloet, Eric G. Krause, Thomas Unger, and U. Muscha Steckelings. "Angiotensin Type 2 Receptors: Blood Pressure Regulation and End Organ Damage." Current Opinion in Pharmacology 21 (April 2015): 115–21. https://doi.org/10.1016/j.coph.2015.01.004.
  • Sun Zhongjie. "Aging, Arterial Stiffness, and Hypertension." Hypertension 65, no. 2 (February 1, 2015): 252–56. https://doi.org/10.1161/HYPERTENSIONAHA.114.03617.
  • Tam, Wilson, Susanna S. Ng, Kin?Wang To, Fanny W. Ko, and David S. Hui. "The Interaction between Hypertension and Obstructive Sleep Apnea on Subjective Daytime Sleepiness." The Journal of Clinical Hypertension 21, no. 3 (March 2019): 390–96. https://doi.org/10.1111/jch.13485.
    te Riet Luuk, van Esch Joep H.M., Roks Anton J.M., van den Meiracker Anton H., and Danser A.H. Jan.
    "Hypertension." Circulation Research 116, no. 6 (March 13, 2015): 960–75. https://doi.org/10.1161/CIRCRESAHA.116.303587.
  • "The Hypertension Treatment Algorithm Made Simple." American Medical Association. Accessed March 22, 2019. https://www.ama-assn.org/delivering-care/hypertension/hypertension-treatment-algorithm-made-simple.
  • "Types of Blood Pressure Medications." www.heart.org. Accessed March 22, 2019. https://www.heart.org/en/health-topics/high-blood-pressure/changes-you-can-make-to-manage-high-blood-pressure/types-of-blood-pressure-medications.
  • "Vasopressin, Central Autonomic Control and Blood Pressure Regulation - ProQuest." Accessed March 13, 2019. https://search.proquest.com/openview/f6d0d68bf825c44f50bd2e5fc0412c7c/1.pdf?pq-origsite=gscholar&cbl=326347.
  • Viera, Anthony J., and Dana Neutze. "Diagnosis of Secondary Hypertension: An Age-Based Approach." American Family Physician 82, no. 12 (December 15, 2010): 1471–78.
  • Whelton, Paul K., Robert M. Carey, Wilbert S. Aronow, Donald E. Casey, Karen J. Collins, Cheryl Dennison Himmelfarb,
    Sondra M. DePalma, et al. "2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults." Journal of the American College of Cardiology 71, no. 19 (May 2018): e127–248. https://doi.org/10.1016/j.jacc.2017.11.006.
  • Wiysonge, Charles S, Hazel A Bradley, Jimmy Volmink, Bongani M Mayosi, and Lionel H Opie. "Beta-Blockers for Hypertension." The Cochrane Database of Systematic Reviews, no. 1 (January 20, 2017). https://doi.org/10.1002/14651858.CD002003.pub5.
  • Wright, James M, Vijaya M Musini, and Rupam Gill. "First-Line Drugs for Hypertension." Edited by Cochrane Hypertension Group. Cochrane Database of Systematic Reviews, April 18, 2018. https://doi.org/10.1002/14651858.CD001841.pub3.